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"'t"'-\ Industry Services Division County <br /> ' 1400 E Washington Ave �V Nell- <br /> PIS P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S _ Madison,WI 53707-7162 �� <br /> A55-3i <br /> :_�k-. ; .5 I- 20-T`',' <br /> Sanitary Permit Application <br /> State <br /> accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �/�/ err� <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. bvLfd Dr. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Q�-- // 2, r Parcel# 1 Vitt <br /> ier4 d //2oKik1n'e, 07-0/7-2-w-6=-27- 'is-No-m7000 <br /> Property Owner's Mailing Address /� Property Location <br /> yG7Z 233 Al� Govt.Lot <br /> City,State Zip Code Phone Number V., /, Section Z 3 <br /> ipidkj- Heir' <br /> `7 WC// N d 3 1 ,J fr[cle oyej-1 <br /> T '/0 N; R (`� Eo <br /> H.Type of Building(check all that apply) Lot# <br /> ri1 or 2 Family Dwelling-Number of Bedrooms , /171/`/ Subdivision Name <br /> Block# V b — 0 U /el�it / e ,to� <br /> ❑Public/Commercial-Describe Use Qbtu u <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> VI Town of -,1 C,n,1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> gi New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> M Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4/57) . 7 60 6yie, y {j 6,2.i"6/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> B <br /> Gallons Gallons Units L o° <br /> New Tanks Existing Tanks w y Ti4 '42 <br /> 2 <br /> n. U in y cn 4, 0 D. <br /> Septic or Holding Tank //h/,/ /^y, /$ L e d� J <br /> Dosing Chamber /MO <br /> — WV -/' 7/� J` <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumbe' t attire MP/MPRS Number Business Phone Number <br /> A704* T gAd17 "7 957-/ 7/5-sV-0Z0Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6681 AMI f <br /> I le , kie6s LA' 54459, <br /> VIII.County/Department Use Only <br /> pprovcd ❑ Disapproved <br /> Permit FeeeeDate Issue umg gent Signatu <br /> 0 Owner Given Reason for Denial S 3 5. oe 01� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 417teaulletta mast {It S&FP 1 we4t. <br /> 0 RinAtit IS retdrte[ 'fir4144901044444)44p44.4*. IP E 0'v Et <br /> Dra*A. to **4d 4 loltwtc. scdisohks. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches <br /> MAY 1 tl 2D2O J <br /> SBD-6398(R.08/14) Burned County <br /> ' Land Services Department <br /> �7I( <br /> l b :B95T- tLf25.°° <br />